PARTICIPANT PENSION BENEFIT APPLICATION

NATIONAL ELECTRICAL BENEFIT FUND NEBF

PARTICIPANT PENSION BENEFIT

APPLICATION

Rev 01/12

2400 Research Boulevard, Suite 500, Rockville, MD 20850-3266 Telephone (301) 556-4300

RETURN TO WORK POLICY

If you are receiving an early or normal retirement benefit:

? You must immediately notify the NEBF if you return to work in the electrical industry for forty (40) or more hours per month.

? If you are receiving an early or normal retirement benefit and you return to work in the electrical industry for forty (40) or more hours per month, your benefit will be suspended until such time that you actually retire. Any hours worked in covered employment after you return to work will be included in the calculation for your eventual pension benefit. No deduction will be made in your benefit on account of your return to work.

If you are receiving a disability benefit:

? You must immediately notify the NEBF if you return to any substantial gainful employment or if you are no longer disabled.

? If you are receiving a disability benefit and you return to any substantial gainful employment, your disability benefit will cease and you will no longer be considered disabled for NEBF purposes.

Failure to notify the NEBF of subsequent employment:

? If you return to work in the electrical industry (or return to any work if you are receiving a disability benefit) and do not inform the NEBF, when the NEBF becomes aware of such employment, the NEBF will presume that you are working for forty (40) or more hours per month (or that you are no longer disabled) and will suspend your benefit. You will be required to refund any improper benefits received while employed and the NEBF is authorized to deduct any amount owed from your future pension benefits. If you are receiving a normal or early retirement pension benefit when you return to work, the amount of the deduction may be up to 100% of all monthly benefits due you for the first three months and 25% of all monthly benefits thereafter. The deduction may also continue against your spouse's benefit after your death. You may rebut any presumption made by the NEBF by supplying acceptable information concerning your work status and you can appeal any suspension under the claims and appeals procedures found in the Summary Plan Description.

Applicable Department of Labor Regulations may be found in Section 2530.203-3, Title 29 of the Code of Federal Regulations. The NEBF's rules may be found in Section 15 of the Plan of Benefits for the NEBF.

PLEASE RETAIN THIS PAGE FOR YOUR RECORDS

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National Electrical Benefit Fund

Participant Pension Benefit Application

To avoid delays in the process and receipt of your benefit, please follow these instructions carefully and completely.

1. Print all information requested. 2. Read and respond to each page carefully. 3. Remember to attach supporting documentation. 4. Remember to sign and date this application. 5. Submit original application. Faxes and Xerox copies will not be accepted. Once your completed application and the required documents are received, the Fund will send you a letter acknowledging receipt of the application. If you do not receive a letter within 30 days, you should contact the Fund's office. If your claim is denied, a written notice of the reason for denial of benefits will be sent to you. PLEASE MAIL COMPLETED APPLICATION WITH ATTACHMENTS TO: National Electrical Benefit Fund Suite 500 2400 Research Blvd Rockville, MD 20850-3266 If you have any questions about the National Electrical Benefit Fund or this application, you may call the Fund's office at 301-556-4300 or visit our website at .

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Proof of Age

To be eligible for a pension, you are required to submit proof of age. Submitting one clear photocopy from the Primary Proof list (below on the left) satisfies the proof of age requirement. However, if you cannot submit one primary document, submitting two clear photocopies from the Secondary Proof list (below on the right) may satisfy the proof of age requirement.

Note: If your name on your pension application differs from your name on your proof of age, you must also submit documentation substantiating your name change (marriage certificate, etc.).

Note: If you are presently married, you are required to submit proof of marriage and your spouse is required to submit the proof of age.

Note: If there is a difference between the last name on your spouse's birth certificate and your marriage certificate, you must also submit proof of your spouse's name change (previous marriage certificate, divorce decree, etc).

Primary Proof ? One Required 1. Birth Certificate 2. Baptismal Certificate 3. Registration of Birth 4. Naturalization Papers 5. Immigration Papers 6. Passport 7. Hospital Birth Record

Secondary Proof ? Two Required

O

1. A signed statement by the physician or midwife in attendance

R

at birth. This statement must be notarized.

2. U.S. Census Record. Forms are available through the Post Office.

3. School record certified by the custodian of such records.

4. Military discharge papers.

5. Vaccination record certified by the custodian of such records.

6. The signed application for a life insurance policy and attached insurance policy bearing the age or date of birth of applicant.

7. Marriage records showing the date of birth or age. Application for marriage license, marriage certificate, or church record certified by the custodian of such records.

8. Child's birth certificate showing your age at the time of their birth.

Note: If any of these documents are in a foreign language, a certified English translation is required.

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NEBF Participant Pension Benefit Application '**

1 Participant

What type of pension are you applying for?

Normal

Early

Disability

When is your planned retirement date from the electrical industry or onset date of disability?

/

/

Month

Day

Have you been approved for a Social Security Disability Benefit? Yes

Year

No

Pending

Date of Social Security Disability Award:

/

/

Month

Day

Year

Briefly describe your disability and include supporting documentation.

Participant's Social Security Number

-

-

One marital status must be checked:

Single

Married

Mr.

Mrs.

Ms.

Miss

First Name

Divorced

Date of Birth

/

/

Month

Day

Year

Widowed

Male

Female

Middle Name

Last Name

Mailing Address Line 1

Mailing Address Line 2

City

State

Zip Code\Postal Code

-

Country of Citizenship

EMAIL ADDRESS:

Telephone Number

-

-

US Citizen

Yes

No

US Resident Yes

No

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NEBF Participant Pension Benefit Application '**

2 Current Spouse

If you are currently married, please provide the following information concerning your spouse.

Spouse's Social Security Number

-

-

Mr.

Mrs.

Ms.

Miss

First Name

Spouse's Date of Birth

/

/

Month

Day

Year

Date of Marriage

/

/

Month

Day

Year

Middle Name

Last Name

Maiden Name

If your spouse has ever gone by a name other than the one listed on your marriage certificate, please send documentation.

3 Participant's Former Spouse(s)

If you have been previously married, please provide the information below. Note: If divorced, submit complete copies of all signed Divorce Decrees and Marital Settlement Agreements. Do not list your current spouse.

Former Spouse(s) Name

LIST ALL PREVIOUS SPOUSE(S)

Date Married

Date Marriage Ended

Reason (Divorce, Death, Etc.)

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NEBF Participant Pension Benefit Application '**

4 Joint and Survivor Annuity Benefit

Section 16 of the Plan of Benefits for the NEBF provides that a married participant shall receive, instead of the monthly benefit to which he/she is entitled, a reduced monthly benefit for as long as he/she lives, with the provision that after his/her death, one-half (1/2) or three-quarters (3/4) of such reduced monthly benefit shall continue to be paid to his/her eligible spouse so long as such spouse survives him/her, unless the participant elects, in writing, with the written consent of his/her spouse, not to receive such a "joint and survivor annuity benefit". If the participant and his/her spouse elect not to receive the "joint and survivor annuity benefit", then the participant will receive a "single life benefit", which will provide for a larger monthly pension payment for the participant's life, but upon his/her death, payments would cease and there would be no payments to the participant's surviving spouse.The NEBF will send a form to elect or waive the "joint and survivor annuity benefit" at a later date.

5 Militaryy SSeerrvviiccee

If you have ever served in the Armed Forces, you may be entitled to certain service credit(s) for that time. Submit clear copies of military papers.

Date of Entry

Date of Discharge

/

/

Month

Day

Year

/

/

Month

Day

Year

6 Work History

Please provide information regarding your current or most recent employer, last local, last day worked in the electrical industry and last job classification (this includes positions in which you are not actually working with the tools).

Last Local Union #

Initiation Date

/

/

Month

Day

Year

Last Day Worked

/

Month

Day

IBEW Member

Yes

No

/

Year

Job Classification

Employer Name Mailing Address Line 1

Mailing Address Line 2

City

State

Zip Code

-

Telephone Number

-

-

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